May 2023: Medicare Part D Coverage of Antiobesity Medications — Challenges and Uncertainty Ahead
The issue
Medicare is legally barred from covering weight‑loss drugs under Part D, yet newer anti‑obesity injections such as semaglutide (Wegovy) now achieve 15–20 % weight loss in trials and have generated intense demand. These medications cost about $13,600 per year — roughly 20 × older pills — raising fears that mandatory coverage could add tens of billions of dollars to the Part D budget. If just 10 % of Medicare beneficiaries with obesity used semaglutide, annual spending might top $27 billion, or ≈ 18 % of current Part D outlays, while full uptake could exceed the entire program budget.
What do I need to know?
Obesity affects 41 % of older Americans and drives the steepest excess health‑care costs after age 60. Medicare currently pays for these drugs only when prescribed for diabetes, not weight loss, although Congress may overturn the ban through the Treat and Reduce Obesity Act. Independent reviews find semaglutide is not cost‑effective at its list price; the drug would need to fall below ≈ $9,700 per year (and still trail cheaper generics) to meet U.S. value thresholds. Benefits for older adults may also be smaller and side‑effects (nausea, lean‑mass loss) more problematic than in younger trial populations.
Potential risk of high drug costs
Medicare enrollee has BMI 25–29 or mild obesity and is curious about new weight‑loss injections.
Recommended Actions
Ask the clinician about evidence‑based lifestyle programs first; many are covered by Medicare Part B.
Explore inexpensive generic options (phentermine + topiramate ≈ $670 / year) if medication seems appropriate.
Revisit weight and metabolic markers every six months before considering pricier agents.
Imminent risk of coverage gap
BMI ≥ 30 with diabetes, sleep apnea, or heart disease; provider recommends semaglutide but finds no Part D coverage.
Recommended Actions
Request a formal cost discussion: compare expected health gains with out‑of‑pocket expense.
Check state Medicaid, patient‑assistance, or employer plans that sometimes cover anti‑obesity drugs.
Consider starting a lower‑cost generic while monitoring blood sugar, blood pressure, and weight loss.
Confirmed high financial burden
Semaglutide prescription filled; monthly cost overwhelms budget or Part D premiums rise sharply.
Recommended Actions
Discuss dose‑reduction or drug holidays and intensify lifestyle therapy to maintain weight loss.
Appeal to the Part D plan for a tier exception; if denied, talk with the prescriber about switching to covered generics or bariatric‑surgery referral.
Track any side‑effects and document weight, glucose, and quality‑of‑life changes to guide future coverage reviews.
What can I do?
Bring three questions to your next visit: “Am I at potential, imminent, or confirmed risk of costly treatment? What is the health payoff for me at my age? How can we minimize out‑of‑pocket expense?” Keep a weight and medication log, price‑shop pharmacies, and sign up for manufacturer coupons if available. Family caregivers can help compare plan formularies during open enrollment, since a single switch may save thousands per year.
